CTO PCI vs. medical therapy in stable CAD: real-world outcomes from a target trial emulation of SCAAR registry data

Area of Science:

• Cardiology
• Interventional Cardiology
• Health Outcomes Research

Background:

• The prognostic value of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) in stable coronary artery disease (CAD) requires further clarification.
• Existing evidence on CTO PCI benefits in stable CAD is uncertain, necessitating robust real-world data analysis.

Purpose of the Study:

• To assess the long-term survival outcomes of CTO PCI compared to medical therapy (MT) in patients with stable CAD.
• To utilize target trial emulation and a nationwide registry to provide reliable comparative effectiveness data.

Main Methods:

• A nationwide registry (SCAAR) included 7813 patients with stable CAD and CTO from 2015-2024.
• CTO PCI was treated as a time-dependent exposure, with all-cause mortality as the primary outcome.
• Advanced statistical methods including IPTW, time-dependent Cox regression, and IV analysis were employed to mitigate confounding.

Main Results:

• Over a median follow-up of 5.08 years, unadjusted analysis favored CTO PCI, but adjusted analyses (IPTW, IV) showed no significant mortality difference versus MT.
• Successful CTO PCI was linked to improved survival, whereas unsuccessful procedures did not demonstrate a benefit.
• Subgroup analyses revealed no consistent benefits, with a potential modest advantage observed in non-diabetic patients.

Conclusions:

• CTO PCI in stable CAD, when emulated as a target trial, was not associated with improved overall survival compared to MT in a large nationwide study.
• The success of the CTO PCI procedure is critical, as only successful interventions conferred a survival advantage.
• These findings underscore the importance of procedural success and careful patient selection for CTO revascularization strategies.